[PDF] LITERATURE REVIEW ON FACTORS AFFECTING THE UTILIZATION OF

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LITERATURE REVIEW ON FACTORS AFFECTING THE UTILIZATION OF

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LITERATURE REVIEW ON FACTORS AFFECTING

THE UTILIZATION OF FAMILY PLANNING

SERVICES AMONG WOMEN LIVING WITH HIV IN

TANZANIA

JEAN GILLEARD LYATUU

TANZANIA

48TH International Course in Health Development

September 19, 2011 ± September 7, 2012

KIT (ROYAL TROPICAL INSTITUTE)

Development Policy & Practice/

Vrije Universiteit Amsterdam

A literature review on factors effecting the utilization of family planning services Among Women Living With HIV in Tanzania. A thesis submitted in partial fulfilment of the requirement for the degree on Master of Public Health By

Jean Gilleard Lyatuu

Tanzania

Declaration:

internet or any other source) this has been carefully acknowledged and referenced in accordance with departmental requirements.

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48Th International Course in Health Development (ICHD)

September 19, 2011 ± September 7, 2012

KIT (Royal Tropical Institute)/ Vrije Universiteit Amsterdam

Amsterdam, The Netherlands

September 2012

Organized by:

KIT (Royal Tropical Institute), Development Policy & Practice

Amsterdam, The Netherlands

In co-operation with:

Vrije Universiteit Amsterdam/Free University of Amsterdam (VU)

Amsterdam, The Netherlands

i

Table of Contents

LIST OF FIGURES .............................................................................................. II

LIST OF TABLES ................................................................................................ II

DEDICATION ................................................................................................... III

ACKNOWLEDGEMENT ....................................................................................... IV

DEFINITION OF TERMS ...................................................................................... V

ABBREVIATION ................................................................................................ VI

ABSTRACT ....................................................................................................... VII

INTRODUCTION............................................................................................. VIII

CHAPTER ONE: BACKGROUND INFORMATION .................................................... 1

1.1 TANZANIA PROFILE ............................................................................................ 1

1.2 HEALTH SECTOR .............................................................................................. 1

1.3 HUMAN RESOURCE FOR HEALTH ............................................................................. 3

1.4 FAMILY PLANNING SITUATION IN TANZANIA ............................................................... 3

1.5 HIV IN TANZANIA ............................................................................................ 5

1.6 UNMET NEEDS ................................................................................................. 6

CHAPTER TWO: PROBLEM DESCRIPTION, OBJECTIVES AND METHODOLOGY ..... 7

2.1 PROBLEM DESCRIPTION ...................................................................................... 7

2.2 OBJECTIVES ................................................................................................... 8

2.3 METHODOLOGY -LITERATURE REVIEW ................................................................. 8

2.4 CONCEPTUAL FRAMEWORK ................................................................................... 9

2.5 LIMITATION OF THE STUDY ................................................................................. 11

CHAPTER THREE: POLICY RELATED FACTORS-RESULTS ................................... 12

3.1 NATIONAL HEALTH POLICY ................................................................................ 12

3.2 RIGHT TO ACCESS AND UTILIZE FAMILY PLANNING SERVICES ......................................... 14

3.3 AVAILABILITY, USE AND APPROPRIATENESS OF FAMILY PLANNING SERVICES GUIDELINE .......... 15

3.4 AVAILABILITY OF HUMAN RESOURCE ...................................................................... 15

3.5 SUMMARY OF POLICY RELATED FACTORS ................................................................. 16

CHAPTER FOUR: SERVICE RELATED FACTORS.................................................. 18

4.1 SKILLS AND ATTITUDE OF HEALTH CARE PROVIDERS ................................................... 18

4.2 AVAILABILITY OF FAMILY PLANNING SUPPLIES ........................................................... 19

4.3 ACCESS TO AFFORDABLE FAMILY PLANNING SERVICES FOR HIV POSITIVE WOMEN ................. 20

4.4 ACCESS TO QUALITY FAMILY PLANNING SERVICES ...................................................... 21

4.5 AVAILABILITY OF USER FRIENDLY SERVICES ............................................ 21

4.6 LINKAGE OF FAMILY PLANNING AND HIV SERVICES .................................. 21

4.7 SUMMARY OF SERVICES RELATED FACTORS .............................................................. 22

CHAPTER FIVE: CLIENTS RELATED FACTORS .................................................... 24

5.1 KNOWLEDGE ABOUT FAMILY PLANNING AND USE ...................................................... 24

5.2 FERTILITY DESIRE ........................................................................................... 24

5.3 EDUCATION LEVEL .......................................................................................... 25

5.4 HIV STATUS ................................................................................................ 26

5.5 SUMMARY OF CLIENT RELATED FACTORS ................................................................. 26

CHAPTER SIX: COMMUNITY RELATED FACTORS .............................................. 27 ii

6.1 MISCONCEPTION AND ACCEPTANCE OF FAMILY PLANNING METHODS ................................. 27

6.2 RELIGION BELIEFS .......................................................................................... 27

6.3 CULTURAL INFLUENCE, FAMILY AND PARTNER SUPPORT ................................................ 28

6.4 SUMMARY OF COMMUNITY RELATED FACTORS ........................................................... 28

CHAPTER SEVEN: DISCUSSION, CONCLUSION AND RECOMMENDATION .......... 29

7.1 POLICY RELATED FACTORS ................................................................................ 29

7.2 SERVICE RELATED FACTORS ............................................................................... 31

7.3 CLIENTS AND COMMUNITY RELATED FACTORS .......................................................... 33

REFERENCE ...................................................................................................... 36

ANNEXES .......................................................................................................... 44

ANNEX1: MAP OF TANZANIA ................................................................................... 44

ANNEX 2: THE CURRENT CONTRACEPTIVE USE BY AGE ...................................................... 45

ANNEX 3: CONCEPTUAL FRAMEWORK FOR HIV PREVENTION ............................................. 46 ANNEX 4: CONCEPTUAL FRAMEWORK FOR FERTILITY DESIRE ............................................ 47 ANNEX 5: CONCEPTUAL FRAMEWORK ON THE UTILIZATION OF FAMILY PLANNING AMONG SEXUALLY

ACTIVE HIV PEOPLE .............................................................................................. 48

LIST OF FIGURES

Figure 1: Organization of Health Services in Tanzania ........................... 2 Figure 2: The percentage of married women using family planning in Tanzania from 1991-2010 ................................................................. 5 Figure 3: Adapted Conceptual Framework (Egessa, 2010) ................... 10 Figure 4: Sources of family planning supply verses the use in Tanzania . 19 Figure 5: Family planning discussion in HIV care & treatment clinic ....... 25

LIST OF TABLES

Table 1: Types of health facilities and ownership .................................. 2 Table 2 : Summary of Human Resorce for Health Situation .................. 16 iii

DEDICATION

This thesis is dedicated to my lovely parents Mr& Mrs Gilleard Reuben Lyatuu for their encouragement, spiritual and moral support towards my studies and life. iv

ACKNOWLEDGEMENT

I thank God for giving me His guidance throughout the year and good health. For caring for my parents and others who depend on my support. My sincere gratitude and thanks goes to Netherland Organization for international cooperation (NUFFIC) for granting me scholarship to pursue my Masters studies here in Netherland. My heartfelt goes to the course administration and coordination and the whole education team in Royal Tropical Institute (KIT) for their support and guidance towards my studies and knowledge gained which will develop my career My very special thanks go to my thesis back stopper, whom I have worked with closely since the initial development to the end. A special word goes to my parents, who kneeling down and call God with all their faith and ask for my success, I should not forget to mention my elder sister Jane, who decide to step on my shoes throughout my absence despite her being in a Masters course also. IMVPO\ P\ ŃOMVVPMPHV HF+G ³ŃRORUP JURXS´ IRU PMNLQJ POH \HMU HQG peaceful and joyful with lots of fun and sharing of constructive ideas. I will miss them. v

DEFINITION OF TERMS

Accessibility of services

proximity/ distance to reach the services area Dual protection Is the strategy used to prevent both unwanted pregnancy and sexual transmitted infections including HIV where there is correct and consistence use of condom in conjunction with other contraceptive method

Family planning

is allowing individual or couples to have the desired number of children they want and at what interval.

Family planning methods

are methods used to prevent pregnancy or space children or limit the number of children

Fertility desire

need/wish for couples or individual to reproduce

Misconception

false perceptions Modern family planning Hormonal contraceptive methods that includes: oral, injectables and barrier methods Natural family planning Methods includes calendar, rhythm and breastfeeding

Utilization

Use Permanent family planning Includes surgery (bilateral tubulisation and vasectomy)

Primary level

First level of contact in health care

service can be at the community or dispensary or health centre.

Secondary level

Second level of health care services

District hospital

Tertiary level

advanced/specialised level of health services

Traditional family planning Differ with tribes

Unmet need

is the discontinuation between she does to avoid or prevent pregnancy vi

ABBREVIATION

ANC Ante-Natal Care

ART Anti-Retroviral Therapy

FHI Family health international

FP Family Planning

HIV Human Immune Virus

HSR Health Sector Reform

HSSP Health Sector Strategic Plan

IUCD Intra Uterine Contraceptive Devise

LGA Local Government Authority

MCHA Maternal and Child Health Aide

MOHSW Ministry of Health and Social Welfare

MSD Medical Store Department

MST Marie Stopes Tanzania

NACP National AIDS Control Program

NBS National Bureau of Statistics

NBS Tanzania Demographic Health Survey

NHA National Health Account

NIMR National Institute for Research

NPGRCH National Policy Guideline for Reproductive and Child health

PMTCT Prevention of Mother To Child Transmission

PRSP Poverty Reduction Strategic Plan

PSI Population Service International

RCH Reproductive and Child Health

RH Reproductive Health

SSA Sub-Sahara Africa

STI Sexual Transmitted Infection

TACAIDS Tanzania Commission for AIDS

TBS Tanzania Baseline Survey

THMIS Tanzania HIV/AIDS and Malaria Indicator survey

UNAIDS United Nation on HIV/AIDS

UNGASS United Nations General Assembly

URT United Republic of Tanzania

VCT Voluntary Counselling and Testing

WHO World Health Organization

vii

ABSTRACT

Background: Despite known advantages of family planning (FP) services, there has been a slow increase in uptake of services in Tanzania. HIV and guidelines have ensured access to free Reproductive Health (RH) and FP services. Several challenges contributed to low uptake of family planning services in HIV positive women. Objective: To determine relevant factors affecting the utilization of FP services among women living with HIV and provide recommendations to improve the uptake of FP services. Method: Literature review done on utilization of family planning services among HIV positive women in Tanzania and SSA. Findings: A combination of factors contributes to low uptake of FP services in HIV positive women these includes policy and services delivery related factors studied focused on public, private, private for profit providers. Unavailability of FP guideline is among challenges observed that are within government capacity to improve RH services including FP to HIV positive women. Other factors were related to clients and community. Knowledge on FP services is importance to HIV positive women is a major issue. CONCLUSION: In spite efforts by the government to improve access to FP services, women living with HIV are not targeted. It is important for the government to replicate efforts of FP implementing partners and roll out FP services to HIV positive women. RECOMMENDATION: The government should reinforce RH policy to ensure FP services to HIV positive women and educate community on benefits of modern FP to HIV positive women. Key words: Utilization; socio-cultural practices; family planning; fertility desire; HIV

Word count: 11,174

viii

INTRODUCTION

As midwife with clinical and administrative experience, I faced several challenges in implementation of RH interventions at different levels of health services. My interest was particularly in HIV reduction strategies and family planning (FP) implementation. A particular concern from my personal experience was the challenges faced by HIV positive women in accessing FP services. In Tanzania the unmet need for FP is currently at 50% and contraceptive prevalence is 29 % (NBS, 2010).HIV prevalence in the country is 5.7% and is 9% among pregnant women. This data accounts for the total population. Globally the prevalence rates of the contraceptives are 63% and Unmet need for family planning is 11% (WHO, 2010). FP is among 7 components of RH which includes; Safe Motherhood, Family Planning, prevention mother to child transmission, malaria, expanded program of immunization, integrated management of childhood illness and adolescents. The implementation has been a challenge in the country. There is a chronic scarcity of resources in RH with limited funding and human resources. The FP services are offered free of charge to all women in the country however utilization still remains a challenge. The NBS (2010) reports low utilization of FP services among women aged

15-49. Speizer (2007) reported on provider related barriers to accessing

FP resulting in low utilization of services in general. Currently there are no studies done to assess access and utilization of FP services amongst HIV positive women in Tanzania. I would like to conduct a study on factors affecting utilisation of FP use among HIV positive women. The study is literature review based on literature available and personal experiences. The results of my study will be shared with the RH department in the Ministry of Health. This paper comprises of seven chapters whereby chapter one provides background information of Tanzania including health sector information related to FP use. Chapter two describes the problem, objectives and methodology. The study findings are explained in three, four, five and six and chapter seven contains the discussion conclusion and recommendations. 1

CHAPTER ONE: BACKGROUND INFORMATION

1.1 Tanzania profile

United Republic of Tanzania is among East African covering approximately

94,500 square kilometres. About 60,000 square kilometres of the land

surface is covered by water (includes 5 big lakes). Climatic conditions include two rainfall seasons, March to May ranging from minimum to heavy rains. A long dry period extended from June to October (NBS, 2010)
Tanzania has an estimated population of 43,187,823 (2012 census projection) with a growth rate of 2.4% per year and fertility rate 5.4 per child birth in a year (NBS, 2010). The life expectancy at birth for male and female lies between 53/58 years and the under 5 mortality is 108 in

1000 live births. Approximately 65% of the population is below the age of

25 (MOHSW, 2008b).

The country has political stability with an increasing Gross Domestic Product rate of 6.7% per year. Despite this increase, an estimate of 57% of the population is living under the poverty line of $1 per day (MOF,

2011).

1.2 Health Sector

In Tanzania, the health sector strategic plans and poverty reduction successful implementation of the health policy. These set of free policies includes access to maternal health services (UNFPA, 2011). The health system in Tanzania covers the village health post referral up to tertiary level. The health system reforms led to decentralization in the chain of service delivery. The reforms included a merger of Ministry of Health (MOH) and Ministry of Social Welfare (MOHSW) in 2006. Provision of services is divided into three levels. The primary level comprise of village health posts, dispensaries and health centres. The village health posts were identified to serve at household level through trained village health workers (VHW) who provide basic FP services. Dispensaries work within the population of 10,000 within 5km radius. It provides basic primary health care and supervises the village health posts. The Health centres works within the population of 50,000 and provide a higher level of service compared with the dispensary. It has the capacity 2 to perform minor procedures including 24hours admission. FP services are also available. The secondary level contains District Hospital as the first referral. It serves up to 250,000 populations with specialised medical personnel to provide back-up surgery, meeting obstetrical emergencies and other life saving procedures and referral services. They provide access to comprehensive family planning. Permanent family planning services (Vasectomy, tubal ligation) are also available. The tertiary level includes the regional hospital and advanced specialized services. It serves up to 1,000,000 populations. The tertiary level of health care is mostly teaching institutions with all advanced technology (MOHSW, 2007a). Major medical/ gynaecological conditions, post abortion care, management of infertility are performed. Figure 1: Organization of Health Services in Tanzania (Source: http://www.moh.go.tz, 2006) Delivery of health services is by the public and private sector. However the public sector through MOHSW covers 60% while the private sector covers 30% and private for profit covers 5% of health service delivery (NHA, 2006).

Table 1: Types of health facilities and ownership

Type OWNERSHIP TOTAL

GOVERNMENT PRIVATE/PARASTATAL FBO

National

Hospital

1 - - 1

Specialized

Hospital

5 2 - 7

Regional

Hospitals

21 - - 21

3

District

Hospital

55 35 13

Health centre 379 61 125 565

Dispensaries 3324 924 658 4930

Source: MOHSW 2008b

The Health Sector Strategic Plan has 5 components of which three among the strategies have an impact on increasing utilization of family planning to women living with HIV. These include; health promotion at primary level, preventive services and care and treatment at secondary level (MOHSW, 2008c).

1.3 Human resource for health

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